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2 Specialties Stroke medicineStroke medicineDr Helen Newton BM FRCP Consultant physician1 Description of the specialtyStroke is the most common cause of severe disabilityand the third most common cause of death in the UK. Itcosts the economy £8 billion a year (£3 billion in NHScosts; over 5% of NHS resources). 1 Consultantsspecialising in stroke are based in several specialties,commonly geriatric medicine or neurology. They arerepresented by the British Association of StrokePhysicians (BASP) who define the competencies androles of stroke specialists 2 and the stroke trainingcurriculum (www.basp.ac.uk).In an unprecedented development of stroke services, allhospitals in the UK now have a stroke unit and aneurovascular (transient ischaemic attack, TIA) clinic.Seventy-four per cent offer 24-hour thrombolysis.However, improvements in acute care are not yetmatched by progress in delivering more effectivepost-hospital support. 3Who are the patients?A hospital serving a population of 300,000 admits about500 acute stroke patients each year. 4 Stroke servicesneed to plan for a further 20–25% of patients whopresentwithstrokemimics.ThecohortreferredtoTIAclinics contains a higher proportion of patients withalternative diagnoses, reflecting diagnostic uncertainty.The hospital described above might receive up to 500such referrals per year. Twenty-five per cent of patientsare under 65. People from certain ethnic minorities areat a higher risk. Stroke patients need specialistrehabilitation either in hospital or at home, and toaccess further rehabilitation and support, often formany years.Main disease patternsStroke and TIA are part of the same spectrum ofdisease. By convention, TIA is diagnosed wheresymptoms resolve within 24 hours, but this is not auseful distinction. Stroke and TIA should be managedin an integrated service. Patients with subarachnoidhaemorrhage have similar needs (eg rehabilitation) buta different pathway for acute care which is notaddressed here.2 Organisation of the service and patternsof referralA typical serviceA typical service comprises the following: Neurovascular (TIA) clinic: patients with suspectedTIAwhoareathighriskofstrokeshouldbeseenandinvestigated within 24 hours, and all others within 7days. 5 A 7-day service with immediate accessto appropriate brain and vascular imaging isneeded. Hyperacute stroke service: people with suspectedstroke must be conveyed immediately to a hospitalproviding thrombolysis 24 hours a day 5 andadmitted directly to a hyperacute stroke unit(HASU). 6 Twenty-four hour availability of anexperienced stroke physician and immediate accessto brain imaging is needed. Hospitals that cannotprovide a full hyperacute service participatein telemedicine schemes which are becomingwell established and researched. Some hospitalscontinue to need to operate a bypass arrangementto convey stroke patients to the nearest suitablehyperacute service ensuring that there are robustarrangements for this with emergency serviceproviders. 6 Acutestrokeunit(ASU):all hospitals admittingpeople with stroke must ensure that patients areadmitted directly to an ASU (or HASU). SUs shouldmeet specific geographical, organisational andstaffing crtieria. 6 Rehabilitation stroke unit (RSU): different modelsare effective including integration with the acuteunit and separate units in acute, intermediate orcommunity settings. Better outcomes are achievedwhen stroke professionals oversee care. 7 Early supported discharge should be provided forsuitable patients and should consist of the sameintensity and skillmix as in hospital, without delay indelivery. 6 Long-term management of disablity: awiderangeofrehabilitation and support services must beprovided for patients and carers.C○ Royal College of Physicians 2013 255
Consultant physicians working with patientsBox 1 Characteristics of effective stroke unitsKey characteristics of all stroke units 3Consultant physician with responsibility for strokeFormal links with patient and carer organisationsMultidisciplinary meetings at least once a week to plan patient careProvision of information to patients about strokeFunding for external courses and (monitoring of) uptakeAdditional key characteristics of acute stroke units 3Continuous physiological monitoring (ECG, oximetry, blood pressure)Immediate access to scanningDirect admission from A&E/front door (
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